Provider Demographics
NPI:1518116961
Name:WALLEN, ARTHUR M (MS)
Entity Type:Individual
Prefix:
First Name:ARTHUR
Middle Name:M
Last Name:WALLEN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9434 SW 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3243
Mailing Address - Country:US
Mailing Address - Phone:352-339-5197
Mailing Address - Fax:
Practice Address - Street 1:10929 NW 35TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-4972
Practice Address - Country:US
Practice Address - Phone:352-339-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-03-1050103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686363996Medicaid